ADDENDUM: CMA TRAINING - LIST OF COURSE ATTENDEES - …

New Jersey Department of Health Assisted Living Program

APPLICATION FOR APPROVAL OF A CERTIFIED MEDICATION AIDE TRAINING AND COMPETENCY EVALUATION PROGRAM (MATCEP) IN ASSISTED LIVING RESIDENCES/

ASSISTED LIVING PROGRAMS/COMPREHENSIVE PERSONAL CARE HOMES

ADDENDUM: CMA TRAINING - LIST OF COURSE ATTENDEES

INSTRUCTIONS: Please PRINT legibly. This form must accompany the Application for Approval (NA-4) form. It is the School Official's responsibility to verify by checking the registry that each candidate listed below is currently certified in New Jersey using the Online Public Registry at or .

School Name

Class Start Date (mm/dd/yyyy) Name of County

Name of Certified Aide

Date Verified Certificate Type* NJ Certification Number Expiration Date

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

* HHHA-Homemaker/Home Health Aide

NA-Nurse Aide

PCA-Personal Care Assistant

As the School Official, I certify that I have verified by checking the registry that each candidate listed above is currently certified in New Jersey.

Name (Print) of School Official

Contact Number

Signature of School Official

Date

NA-11 OCT 13

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